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Special considerations for gunshot wounds and shrapnel wounds
The basic principles of open/puncture wound care apply, even though of course these wounds are especially sinister versions of punctures. Don't forget that the basics still apply. If they're all you remember, you will do a good job. If you are unsure of the basics, please find someone who is. Gunshots and shrapnel wounds are complicated to care for. That said, I've learned a bit about this stuff, so I'll offer some advice. Shrapnel wounds As for shrapnel wounds, the basic principles apply. They're essentially just punctures with impaled objects. Don't remove the shrapnel. If the shrapnel is still piping hot (it will be if you're on-scene when the injury occurs), DO NOT REMOVE IT. You will want to pull it out. DON'T EVEN TOUCH IT. It's going to be too hot to grab, even if you're wearing a latex glove. But don't use pliers or tweezers, either. IRRIGATE THE SITE. Infection is almost guaranteed with shrapnel wounds. Irrigate and cool them (same procedure) immediately, and get the patient to advanced care even if the wound is not immediately life-threatening. Don't use direct pressure on shrapnel wounds. Most shrapnel wounds won't bleed all that much. So loose, sterile dressing is the way to go. In the event that Emergency Care is unavalable and removal is needed, follow these steps. Deep penetration via debris. *1). Locate entry wound & apply whisky or other solvent liquid. *2) . Attempt to locate exit wound, it will generally be larger than the entry although not always on the other side. *3). if none is found, sterilize a probe and locate ALL debris internally. *4). Using forceps and antiseptic remove all debris. Give stitches to both sides if needed. *5). If wound is to the torso, neck or legs, have an Evac Team remove them on a stretcher to a safe zone. Gunshot Wounds A Gunshot Wound (GSW) can be a intimadating opponent, but worry not since with the correct equipment a GSW is extremely survivable and treatable. In the event of a GSW, follow the HABC flow of treatment; H: Massive Hemorage A: Airway B: Breathing C: Circulation Your first goal in the event of a GSW is to control all hemoraging that has been caused by the round. A rifle round such as a 5.56 mm NATO, found in AR-15 platform rifles, will cause entry and exit wounds, unless the ammunition is frangible, in which case will cause only one entry wound with massive amounts of splintering. In the event that a handgun round has caused a GSW, such as a 9mm found in many service pistols, there may not be an exit wound and the round will still be inside of the wound. Under no circumstances should you ever remove a round that is in a GSW. In order to control the hemorage on a GSW your first course of action is to apply a tourniquet high and tight. Remember that tourniquets may only be used on extremeties. Placing the tourniquet high on the affected extremity is the best action in early treatment. Apply the tourniquet and then check for a pulse on the extremeity, you should feel no pulse. After you have secured your hasty tourniquet you will need to address the bleeding at the wound site. If you are using a hemostatic agent such as quick clot or celox now is the time to apply it to the wound, you should familirize yourself with the use of hemostatics before using them, most companies have extensive training materials online that are free for your use. Your next step is to pack the wound, you can do this with any sterile krinkle gauze such as kerlix. To do this you need to unwrap your guaze and use both pointer fingers to pach the gauze into the GSW with pressure. Never attempt to pack a wound that is not on an extremity, for example head wounds and abdomidal wounds should never be packed. After you have packed the wound you will need to protect it, while mainting pressure. An easy way to do this is with an ETB or emergency trauma bandage, this is bassically a ace bandage wit hgauze buit in and sometimes also featuring a pressure bar. ETBs are relitivley cheap and can be found from various online retailers. If you do not have an etb you can substitute a large amount of gauze and an ace bandage placed over the wound. If you are using an ETB or an ace overwrap you will need to apply a large amount of pressure by wraping tightly. Your secound goal in a GSW situation is to establish an airway on the victim. This can be done with the head tilt chin lift method or the jaw thrust method, the later being more stable for head or spinal GSW victims. Any basic CPR certification will prepare you to render either of the airway methods. If trained you may also use a airway on a GSW victim, a NPA or OPA will both do wonders but you will need to recieve specific training to use either physical airway. Your third goal in a GSW scenario is to monitor breathing, you will do this by looking, listening and feeling for respirations from your victim, once again any CPR class will prepare you for this, as well as also teach you rescue breathing methods. The fourth thing to address in a GSW situation is circualation, check for and monitor your victims pulse and if neccesary render cpr to your victim. The last thing you need to do in a GSW encounter is render immediate casualty evac to you victim. Even with the risk of arrest it is essential that a GSW victim is delivere to a high level of care within one hour of the trauma being inflicted. Afte this so called Golden Hour, survival rates dramatically drop. Treating a Chest GSW If you are unfortunate enough to run into a situation were there is a GSW to the chest, you will need to have the proper equipment in order to render life saving aid. A chest GSW will be very noticible due to the fact that it will literally be a sucking chest wound. You will need to follow the HABC treatment flow described in the last section but you will also need to administer an occlusive, or air tight dressing to the wound. The easiest way to do this is to use a comerically produced chest seal, you will need to wipe up excess blood and then apply a chest seal to the victim on both the entry and exit wounds, remember the exit may be on the victims back. There are two main types of chest seal, the first is a solid occlusive dressing, a street medic should avoid these due to the need to use a chest decompression needle after applying the dressing. These completely air tight dressings will actually cause the lung to collapse inside the cavity in a condition know an tension pneumothorax. Instead you should use a vented chest seal such as a Asherman seal or a Bolin seal. Both are commercially availible to anyone on the internet. Please do remeber that you will need two seals to treat a chest GSW, Plan accordingly. After applying a chest seal you should finsih the HABC flow of treatment and immediatly move the casualty to a higher level of care. Indirect pressure points Remember the indirect pressure points (femoral and brachial). Use them if you can't stop bleeding. You need to be careful with direct pressure on bullet wounds same as shrapnel wounds. If they've hit an artery and are hanging around, you might cause more damage with direct pressure. Even if there is a clear exit wound, with an M16 round you can't be sure the whole bullet exited. Sometimes it splinters. Indirect pressure would in that case be the way to go. Eventually after you treat a few bullet wounds you'll start to recognize how big the exit wounds should be for different sized fragments on different parts of the body. Even then, you cannot be sure there are no fragments left at the wound site. Tourniquet Also, you should find out if the surgeons at the hospitals closest to you know what to do with a tourniquet. If you can talk to the local medics about this, whether they have used TQs and what their success rate has been, you'll get a better idea of whether you want to implement one ever. I can't give advice on protracted care scenarios (1 hour + to advanced care). Maybe others will feel more comfortable advising. It's much more complicated, as goes without saying... However, I can say you should go straight to a TQ anytime there's an amputation or an extreme avulsion involved. As I'm sure you are aware, amputations are pretty common with explosives. Strapping up the stump will be part of your C step during your initial assessment. *OP* Army SOP, at least when I was training, is 60-90 minutes MAXIMUM with a tourniquet. I have have also done this on myself for 45 minutes to procure treatment for a deep leg wound. YMMV, but as far as I know, they're fine for short-term care lasting no longer than 90 minutes. Note by new user: Excerpt from U.S Air Force Survival Handbook: 7-9 a. Bleeding: A tourniquet should be used only after every alternate method has been attempted. If unable to get to medical aid within 2 hours, after 20 minutes, gradually loosen the tourniquet; if bleeding continues, reapply and leave in place. (This loosening/reapplication is an attempt to lessen the likelihood of gangrene) OP's 90 minute recommended timeline is comparable to the 2 hour timeline I've encountered. Notes Please see Initial assessment. This material is intended as a training supplement. Reading this material is no substitute for first aid / medical training with a qualified trainer. We encourage you to pursue ongoing education, reviewing and upgrading your skills-- for the safety of both yourself and anyone you treat. Category:Protocol